Before Assistant Coroner John Taylor
South London Coroner's Court
13 – 30 March 2023

Samuel Howes, 17, died after jumping in front of a train in Croydon on 2 September 2020, just one month before his 18th birthday. The inquest concluded today finding a series of failures by various agencies, including police, mental health and social services, possibly contributed to his death by suicide.

Samuel was from Purley in south London. The youngest of four siblings, he was a much-loved son, brother, nephew, cousin and grandson. A passionate football player and big fan of Crystal Palace, Samuel was happiest when using his talents to write and perform music. His family describe him as a ‘smart, articulate and creative boy who was full of potential.’

In the three years prior to his death, Samuel had been admitted to A&E over 40 times and had 178 contacts with the police.

Samuel’s mental health issues started when he was 13 years old, with OCD, anorexia and self-harm. Samuel soon turned to cannabis in order to self-medicate his anxiety. This progressed to Xanax when he was 14, and his behaviour became more concerning.

Samuel’s mother referred herself to Croydon Council’s safeguarding team for help but found the support offered was generic and ineffective. Samuel also started receiving mental health support from South London and Maudsley child and adolescent mental health services (SLaM CAMHS) around this time.

The inquest heard evidence from two Croydon Social Care managers who both said Samuel was highlighted as a case of huge concern. One had flagged concerns on their first day in the job as they considered the risk was so high.

In her evidence, Samuel’s social worker said that the sight of his self-harm at their first meeting, months before his death, reduced her to tears.  

Samuel continued to struggle with his mental health and drug dependencies and was eventually made the subject of a care order under London Borough of Croydon just before his 16th birthday. He was initially in foster placements, but these broke down as they were unable to meet Samuel’s complex needs.

He was placed in a children’s home and was then housed in two semi-independent placements. Each struggled to deal with the complexity of Samuel’s needs or contain him in the community, as his mental health deteriorated and drug taking escalated.

In her evidence, Samuel’s mother Suzanne told the jury that “Although Samuel was in the care system, I played a significant role in his professional network… I lived and breathed Samuel’s issues. My life revolved around them.”

After Samuel passed his Maths and English GCSEs with flying colours in 2019, he returned to college. However, staff were unaware that Samuel was receiving CAMHS support. Samuel was subsequently excluded as the school was unable to cope with his needs. This had a huge impact on Samuel and led to further deterioration in the months that followed.

In July 2020, Samuel attended three different A&Es and had seven visits in 17 days. On one occasion on 20 July, Samuel’s mother was informed that Samuel had been injured and was being taken to A&E. On arrival, she saw Samuel handcuffed to a trolley and surrounded by five police officers, holding him and shouting instructions at him. Within minutes she was able to calm Samuel, and handcuffs were removed.

In her evidence, Suzanne Howes said that “Samuel's life in the last months of his life could be summed up in that one treatment room scene - mayhem, misunderstanding, trauma, judgement and heartbreak.”

Five weeks before Samuel died there was a meeting between the network of professionals and agencies supporting Samuel. At this time, Samuel reported to social workers that his mental health was 0/10 and that he wanted to jump in front of a train.

Samuel’s social worker gave evidence that the professionals meeting ‘generated a sense of urgency’, due to serious wellbeing concerns and Samuel’s desire to engage. It was her view that Samuel urgently needed to go into secure accommodation or be sectioned. The Director of Croydon Children’s Care said he decided not to put any immediate safety plans in place.

This was not the first time that the possibility of a secure placement had been raised. Mental health professionals had previously suggested this was the best way to keep Samuel safe and provide a circuit breaker.

However, Croydon Social Services had advised the family that this was not being considered. Despite the clear increase in his vulnerabilities, drug taking, self-harming and disclosures to professionals, a secure placement was never obtained for Samuel.

On 30 August 2020, Samuel was arrested by British Transport Police (BTP) and held in police custody whilst under the influence of alcohol. A BTP officer described Samuel banging his head repeatedly and self-harming so badly his clothes were confiscated.

Samuel was left naked on the cell floor. In his evidence the officer described this behaviour as ‘attention seeking’ and ‘fairly normal’.

In custody, Samuel was supposed to see both a custody nurse and a psychiatric liaison nurse. Neither saw Samuel. The psychiatric liaison nurse was specifically told by custody staff that he was ‘well known and violent’ and didn’t need to be seen.

Samuel was released from custody 20 hours later, with no mental health assessment or ongoing safeguarding referral having been completed.

In the evening on 1 September 2020, Samuel was recorded as a missing person by the Metropolitan Police after an incident at his accommodation. Early the next morning, Samuel contacted the London Ambulance Service (LAS) from his friend’s house whilst crying and expressing suicidal thoughts. Police officers visited the address but did not find Samuel there.

Samuel’s level of risk as a missing person was classed by the police as ‘medium’ and this assessment was not escalated to high-risk despite his history and vulnerabilities. There was no active search for Samuel. During the inquest, the police admitted to failings during this final opportunity to save Samuel, accepting the progress made to find Samuel was “zero”.

A few hours later, Samuel died after jumping in front of a train. The inquest concluded that Samuel’s death by suicide was probably contributed to by his mental health and use of drugs and/or alcohol. The jury also found that the following factors also possibly contributed to his death:

  1. The inadequate response of mental health and or social care services in relation to Samuel’s dependency on alcohol and the possibility of a rehabilitative placement
    1. There were inadequate provisions for Samuel’s complex needs. In particular no alternative treatments were proactively pursued. The agencies identified Covid as an obstacle to justify their inadequate responses.
  2. The failure to adequately share risk information by social services and/or mental health services with each other and with the police.
    1. Missing risk assessments were not completed consistently
    2. The Grabs Pack [the form for Looked After Child Information Sharing] was not completed
    3. Samuel’s vulnerabilities and suicide risks were not adequately communicated to the police by social services.
  3. The sharing of risk information by the MPS and/or BTP with partner agencies.
    1. There was a failure to share risk information by the MPS with the BTP, as well as with partner agencies.
    2. In particular, there was a failure to complete and update the [relevant] forms or Merlin [the Met police database on children known to police] as a result of each agency using their own platform.
    3. In addition, the BTP did not access the PNC to identify Samuel’s warning markers.
  4. Steps taken by the MPS to seek an assessment of Samuel’s mental health by a Liaison and Diversion practitioner whilst he was in custody on 30 and 31 August 2020.
    1. Actions noted on [the vulnerability risk assessment] THRIVE regarding the provision of a mental health assessment for Samuel were not followed up on multiple occasions.
  5. The inadequate approach of staff and the safeguarding processes within Croydon Custody Suite.
    1. Samuel's actions were regarding as "attention-seeking"
    2. The safeguarding forms were not completed. 
    3. The limited collaboration between the MPS and BTP led to a lack of recognition of Samuel's mental health needs, resulting in inadequate care. 
  6. Failures by multiple agencies and the inadequate response to the "missing persons" investigation conducted by the MPS
    1. A failure to share information by the different agencies.
    2. Failure by multiple agencies to contact Samuel's family when he went missing. 
  7. Samuel's interactions with his girlfriends
    1. Samuel's relationships were described as "chaotic" and this impacted on his mental health and his behaviour. 
    2. In particular, the texts from his girlfriend telling him to "kill himself" as well as the threats by another girlfriend to end her life, had a significant impact on his behaviour. 

A number of factors were also admitted by the agencies involved in the inquest:

  • Following Samuel’s arrest on 30 August 2020, neither of the safeguarding forms were completed by BTP officers;
  • The MPS did not request Samuel be assessed by healthcare professionals while in custody on 30 to 31 August 2020;
  • The MPS did not progress the investigation to locate Samuel after 3:15am on 2 September 2020 and before actions were set at 08:04am on 2 September 2020.

Samuel’s mother, Suzanne Howes, said “Losing Samuel has been a crushing heartbreak, traumatic beyond our comprehension. Every day and each new experience that we encounter as a family is impacted by his loss. We are changed forever by his death.

Samuel needed and deserved to be safeguarded. He was spiralling, frequently in crisis and returned to self-harming. I along with many professionals feared for his life. He said he wouldn’t live to be 18.

Measures should have been put in place to protect him and provide wrap-around care to manage his safety. Croydon Children’s Services, as his corporate parent, should have led this response.

The Metropolitan Police and British Transport Police should hang their heads in shame. Samuel was crying out for help in custody and severely self-harming. Multiple police officers labelled him ‘attention seeking’. The culture of casual indifference and lack of accountability of both police forces is shocking.

Samuel’s last cry for help went unanswered. He called an ambulance for the first ever time stating he was suicidal, hours before his death. A robust police missing person investigation should have been initiated. Instead, he was failed.

The inquest and its long, chaotic build-up have been brutal and harrowing. Hearing evidence of Samuel’s pain, unanswered cries for help and the many missed opportunities to save him will haunt us forever.”

The full family statement can be found here.

Jodie Anderson, Senior Caseworker at INQUEST said: “Samuel’s death is a stark reminder that the one-size-fits all approach to children’s health, mental health, education and social services support is not working.

That a vulnerable young person like Samuel can interact with so many agencies, at such frequency, and still be left falling through the gaps speaks to the greatest need for change. 

The lack of joined up specialist care for children with complex mental health needs or addictions is a result of the decade long decimation of core services and the deeply imbedded institutional resistance to collaborative, joined-up working.

The persistent adultification, punitive or coercive treatment of vulnerable children, dismissed as ‘attention seeking’, reflect the culture within policing that urgently needs to change to ensure that children are kept safe.” 

Michael Oswald and Niamh McLoughlin of Bhatt Murphy solicitors, representing the family, said: “The jury have made damning findings about mental health and social care services as well as against the British Transport Police and the Metropolitan Police services.  All these organisations must see this as an opportunity to review their practices and make meaningful change to ensure these tragic events are never repeated.”


For further information, please contact Lucy McKay on [email protected] or 020 7263 1111. A photo of Samuel is available here.

The family are represented by INQUEST Lawyers Group members Michael Oswald and Niamh McLoughlin of Bhatt Murphy solicitors and Sam Jacobs and Stephanie Davin of Doughty Street Chambers. They are supported by INQUEST senior caseworker, Jodie Anderson.

Other Interested persons represented are South London and Maudsley NHS Foundation Trust (SLAM), Croydon Social Services, Metropolitan Police Service and British Transport Police.

Journalists should refer to the Samaritans Media Guidelines for reporting suicide and self-harm and guidance for reporting on inquests.